“ FLUID AND BLOOD RESUSCITATION IN ABDOMINAL TRAUMA: IMPORTANT TIPS IN CLINICAL PRACTICE FOR SURGEONS ” Dr. T.C. Kriplani ...
American College of Surgeons Classes of Acute Hemorrhage Factors I II III IV Blood loss <15% (<750ml) 15-30% (750-1500ml) ...
 
Response to blood loss <ul><li>↓ Blood volume. </li></ul><ul><li>↓ Hydrostatic pressure in capillaries. </li></ul><ul><li>...
Asses the loss quickly on clinical grounds <ul><li>If the loss is about 750ml(15%) & patient is haemodynamically stable. <...
If the loss is 1500-2000ml (30-40%) <ul><li>Give crystalloids first, about 2 litres followed by colloid. </li></ul><ul><li...
If the loss is >2000ml(40%) <ul><li>Start crystalloid and colloid. </li></ul><ul><li>Give oxygen. </li></ul><ul><li>Start ...
Which crystalloid is better? <ul><li>Only 25% remain in intravascular compartment. </li></ul><ul><li>Dilutional coagulopat...
Which colloid is better? <ul><li>Costly  </li></ul><ul><li>Allergic reactions </li></ul><ul><li>Infection may be transmitt...
Synthetic colloids <ul><li>Gelatins. </li></ul><ul><li>Dextrans. </li></ul><ul><li>Starch (HES) </li></ul>
GELATINS <ul><li>Prepared by hydrolysis Bovine/Beef collagen. </li></ul><ul><ul><ul><li>Mol.wt.(Da) </li></ul></ul></ul><u...
DEXTRANS <ul><li>Biosynthesized from sucrose by bacteria leuconostoc messenteroides. </li></ul><ul><li>Dextran 70 (6%) </l...
DEXTRAN 40 (10%)  (Lomodex, Plasmex-40) <ul><li>Available in normal saline or in 5% dextrose. </li></ul><ul><li>Dose 8-10m...
STARCH (Hydroxy Ethyl Starch) H.E.S. <ul><li>Made from Amylopectin(Hydrolysis & Hydroxy-ethylation). </li></ul><ul><li>Der...
Physiochemical properties of different H.E.S. preparations HES  70/.5 HES  130/.4 HES  200/.5 HES  200/.5 HES  450/.7 Conc...
H.E.S.(Contd.) <ul><li>HES 130/.4 improves tissue perfusion and oxygenation. </li></ul><ul><li>May ameliorate capillary le...
Indications of Blood Transfusion <ul><li>Human tolerance to Acute Normovolemic Blood loss is about Hb 7gm%.(21-25% HCT). <...
MOST IMPORTANT IS CLINICAL MONITORING <ul><li>1.   B.P. (Invasive more reliable in shock) </li></ul><ul><li>  Radial +(80)...
CLINICAL MONITORING(Contd.) <ul><li>6. Measure O2 extraction (good marker of hypovolemic shock) </li></ul><ul><ul><ul><li>...
BEWARE OF LETHAL TRIAD <ul><li>Hypothermia </li></ul><ul><li>Acidosis  </li></ul><ul><li>Coagulopathy  </li></ul>
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Fluid and blood resuscitation in abdominal trauma

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Fluid and blood resuscitation in abdominal trauma

  1. 1. “ FLUID AND BLOOD RESUSCITATION IN ABDOMINAL TRAUMA: IMPORTANT TIPS IN CLINICAL PRACTICE FOR SURGEONS ” Dr. T.C. Kriplani Professor & Head Department of Anaesthesiology NSCB Medical College JABALPUR (M.P.)
  2. 2. American College of Surgeons Classes of Acute Hemorrhage Factors I II III IV Blood loss <15% (<750ml) 15-30% (750-1500ml) 30-40% (1500-2000ml) >40% (>2000ml) Pulse >100 >100 >120 >140 B.P. Normal Normal ↓ ↓↓ Pulse pressure N or ↓ ↓ ↓↓ ↓↓ Capillary refill <2s 2-3s 3-4s >5s Resp. rate 14-20 20-30 30-40 >40 Urine output ml/hr 30 or more 20-30 5-10 Negligible Mental status Slightly anxious Mildly anxious Anxious & confused Confused Lethargic
  3. 4. Response to blood loss <ul><li>↓ Blood volume. </li></ul><ul><li>↓ Hydrostatic pressure in capillaries. </li></ul><ul><li>Fluid moves from interstitial space to intravascular space. </li></ul><ul><li>Activation of Renin-Angiotensin Aldosterone system. </li></ul><ul><li>Na + retained by kidneys. </li></ul><ul><li>α response causes vasoconstriction which shunts blood from skin, viscera & muscle to preserve blood flow to vital organs. </li></ul>
  4. 5. Asses the loss quickly on clinical grounds <ul><li>If the loss is about 750ml(15%) & patient is haemodynamically stable. </li></ul><ul><ul><ul><li>KVO (Keep the Vein Open) </li></ul></ul></ul><ul><ul><ul><li>No fluid required. </li></ul></ul></ul><ul><li>If the loss is about 1500ml(30%) & B.P. 70 - 90mmHg, but stable, </li></ul><ul><ul><ul><li>Start crystalloid solution. </li></ul></ul></ul><ul><ul><ul><li>Give oxygen. </li></ul></ul></ul><ul><ul><ul><li>Do not raise B.P.(Permissive Hypotension) </li></ul></ul></ul>
  5. 6. If the loss is 1500-2000ml (30-40%) <ul><li>Give crystalloids first, about 2 litres followed by colloid. </li></ul><ul><li>Asses oxygenation of vital organs. </li></ul><ul><li>Give oxygen. </li></ul><ul><li>Think of blood transfusion. </li></ul>
  6. 7. If the loss is >2000ml(40%) <ul><li>Start crystalloid and colloid. </li></ul><ul><li>Give oxygen. </li></ul><ul><li>Start blood transfusion. </li></ul><ul><li>Monitor oxygenation. </li></ul><ul><li>Bring Hb to 7gm%. </li></ul>
  7. 8. Which crystalloid is better? <ul><li>Only 25% remain in intravascular compartment. </li></ul><ul><li>Dilutional coagulopathy, interstitial & chances of pulmonary edema. </li></ul>Crystalloid Osmolarity P H Remarks Recommendations Dextrose 5% 252 4.5 Hypotonic, glucose taken up by cells & water produces oedema. Low PH, ↑blood sugar-brain ischemia. ↑ CO2 production, ↑ lact. Production NEVER BE USED Saline 0.9% 308 (Na 154, Cl 154meq/L) 5.7 Low PH. Hyperchloraemic acidosis is produced. NOT IDEAL Saline 7.5% 2567 (Na 1283, Cl 1283) 5.7 Vol. Exp(250ml->1235ml) Interstitial & cellular dehydration. Rapid rate dangerous. NOT DESIRED Lactated Ringer’s solution 273 (Na 130, Cl 109, K 4, Ca 3, lactate 28) 6.4 Osmolarity near blood Lactate act as buffer. Converted to bicarbonate BETTER Normosol 295 (Na 140, Cl 98, K 5, Acetate 27, Mg 3) 7.4 Mg. can counteract compensatory vasoconstriction NOT DESIRED
  8. 9. Which colloid is better? <ul><li>Costly </li></ul><ul><li>Allergic reactions </li></ul><ul><li>Infection may be transmitted. </li></ul><ul><li>Transport of drugs & endogenous substances. </li></ul><ul><li>(NOT PREFERRED) </li></ul>Albumin Oncotic pressure mm of Hg Vol. expansions Half life 5% 20 70-100% 16-24 hrs 20% 70 300% 16-24 hrs 25% 100 500% 16-24 hrs
  9. 10. Synthetic colloids <ul><li>Gelatins. </li></ul><ul><li>Dextrans. </li></ul><ul><li>Starch (HES) </li></ul>
  10. 11. GELATINS <ul><li>Prepared by hydrolysis Bovine/Beef collagen. </li></ul><ul><ul><ul><li>Mol.wt.(Da) </li></ul></ul></ul><ul><ul><ul><li>Haemaccel (Urea linked) 3.5% 30,000 </li></ul></ul></ul><ul><ul><ul><li>(Na 145, Cl 145, K 5.1, Ca 6.25) </li></ul></ul></ul><ul><ul><ul><li>Gelofusine (Succinylated) 4% 35,000 </li></ul></ul></ul><ul><ul><ul><li>(Na 154, Cl 125) </li></ul></ul></ul><ul><ul><ul><li>Cross linked 5.5% 30,000 </li></ul></ul></ul><ul><li>P H , osmolarity, COP – Near to blood. </li></ul><ul><li>Vol. expansion 70-80%, half life 1-3hrs. </li></ul><ul><li>No dose limit, ?Renal damage. </li></ul><ul><li>Anaphylaxis .03%, Minor reactions 21%. </li></ul><ul><li>WHO has listed Gelatins as essential drug. </li></ul><ul><li>Use abandoned in U.S.A. from 1978. </li></ul><ul><li>Not approved by F.D.A. </li></ul><ul><li>Use has drastically decreased. </li></ul>
  11. 12. DEXTRANS <ul><li>Biosynthesized from sucrose by bacteria leuconostoc messenteroides. </li></ul><ul><li>Dextran 70 (6%) </li></ul><ul><ul><ul><li>Osmolarity 280-324 </li></ul></ul></ul><ul><ul><ul><li>COP 20-30 mm of Hg. </li></ul></ul></ul><ul><ul><ul><li>Vol.Exp. 100% </li></ul></ul></ul><ul><ul><ul><li>Half life 5-6hrs. </li></ul></ul></ul><ul><ul><ul><li>Max. dose(daily) 1.5gm/kg. </li></ul></ul></ul><ul><li>Anaphylactoid reaction, Allergic reaction </li></ul><ul><li>Interference with cross matching. </li></ul><ul><li>↑ bleeding tendency. </li></ul><ul><li>NOT USED NOW </li></ul>
  12. 13. DEXTRAN 40 (10%) (Lomodex, Plasmex-40) <ul><li>Available in normal saline or in 5% dextrose. </li></ul><ul><li>Dose 8-10ml/kg/day. </li></ul><ul><ul><ul><li>Osmolarity 280-324 </li></ul></ul></ul><ul><ul><ul><li>COP 40-60 mm of Hg. </li></ul></ul></ul><ul><ul><ul><li>Vol.Exp. 150-200% </li></ul></ul></ul><ul><ul><ul><li>Half life 3 hrs. </li></ul></ul></ul><ul><li>Anaphylactoid reactions, allergic reactions. </li></ul><ul><li>Interference with cross matching. </li></ul><ul><li>Maximum volume expansion. </li></ul><ul><li>May produce severe cellular dehydration. </li></ul><ul><li>Reduce blood viscosity, improves tissue perfusion. </li></ul><ul><li>AT TIMES USED TO IMPROVE MICROCIRCULATION </li></ul>
  13. 14. STARCH (Hydroxy Ethyl Starch) H.E.S. <ul><li>Made from Amylopectin(Hydrolysis & Hydroxy-ethylation). </li></ul><ul><li>Derived from maize or sorghum or potatoes. </li></ul><ul><li>Can be classified into </li></ul><ul><ul><ul><li>High molecular wt. (1 st Generation) </li></ul></ul></ul><ul><ul><ul><li>(4,50,000) </li></ul></ul></ul><ul><ul><ul><li>Medium MW (2 nd Generation) </li></ul></ul></ul><ul><ul><ul><li>(2,00,000 – 1,30,000) </li></ul></ul></ul><ul><ul><ul><li>Low MW (3 rd Generation) </li></ul></ul></ul><ul><ul><ul><li>(70,000) </li></ul></ul></ul>
  14. 15. Physiochemical properties of different H.E.S. preparations HES 70/.5 HES 130/.4 HES 200/.5 HES 200/.5 HES 450/.7 Concentration 6% 6% 6% 10% 10% Oncotic pressure mm. of Hg 30-36 36 30-37 55-60 25-30 Volume expansion 100% 100% 100% 130% 100% Half life (hrs) 1-2 2-3 3-4 3-4 5-6 Maximum dose ml/kg 33 50 33 33 20 Effect on hemostasis 0 Negligible + ++ +++
  15. 16. H.E.S.(Contd.) <ul><li>HES 130/.4 improves tissue perfusion and oxygenation. </li></ul><ul><li>May ameliorate capillary leakage. </li></ul><ul><li>Hyperviscosity of urine. ? Renal tubular damage. But 130/.4 is safe. </li></ul><ul><li>Some H.E.S. is taken up by reticuloendothelial system and induce pruritis. </li></ul><ul><li>P H around 5.5.(Acidic) </li></ul><ul><li>H.E.S. 130/.4 is preferred colloid at present. </li></ul>
  16. 17. Indications of Blood Transfusion <ul><li>Human tolerance to Acute Normovolemic Blood loss is about Hb 7gm%.(21-25% HCT). </li></ul><ul><li>Start blood transfusion if blood loss > 30-40%. </li></ul><ul><li>FWB(Fresh Warm Blood) is preferred. </li></ul><ul><li>(Experience of American Medics in Afghan & Iraq war 6000 units of FWB was transfused) </li></ul><ul><li>(Crit Care Med. July 2008) </li></ul><ul><li>Beware of complications of massive blood transfusion. </li></ul>
  17. 18. MOST IMPORTANT IS CLINICAL MONITORING <ul><li>1. B.P. (Invasive more reliable in shock) </li></ul><ul><li> Radial +(80), Brachial +(70), Carotid +(60) </li></ul><ul><li> Pulse : Volume </li></ul><ul><li>2. Capillary refill time goes on ↑. </li></ul><ul><li>3. Hb estimation unreliable in acute blood loss. </li></ul><ul><li> (may take 8-12hrs to stabilise) </li></ul><ul><li>4. C.V.P. (may not change upto 30% loss) </li></ul><ul><li>Urine output (hrly.) </li></ul><ul><li> (Lack of urine output in acutely hypovolemic patient is renal success, not renal failure) </li></ul>
  18. 19. CLINICAL MONITORING(Contd.) <ul><li>6. Measure O2 extraction (good marker of hypovolemic shock) </li></ul><ul><ul><ul><li>Pulse oximetry SVO2 </li></ul></ul></ul><ul><ul><ul><li>Normal >95% >65 </li></ul></ul></ul><ul><ul><ul><li>Mild hypovolemia >95% 50-65 </li></ul></ul></ul><ul><ul><ul><li>Severe hypovolemia >95% <50 </li></ul></ul></ul><ul><ul><ul><li>O2 extraction of >50%. Hypovolemic shock usually lactate > 4m.mol/L. </li></ul></ul></ul><ul><li>7. End Exp. CO2 (through nasal prongs) gives online measure of success or failure of volume resuscitation. </li></ul><ul><li>(If pulmonary circulation decreases, End Exp.CO2 goes on decreasing) </li></ul><ul><li>8. Bicarbonate estimation is a good marker of tissue perfusion and oxygenation. </li></ul><ul><ul><ul><li>Normal BE ± 3 m.mol/L </li></ul></ul></ul><ul><ul><ul><li>Mild base def. -2-5 m.mol/L </li></ul></ul></ul><ul><ul><ul><li>Moderate -6-14 m.mol/L </li></ul></ul></ul><ul><ul><ul><li>Severe >-15m.mol/L </li></ul></ul></ul>
  19. 20. BEWARE OF LETHAL TRIAD <ul><li>Hypothermia </li></ul><ul><li>Acidosis </li></ul><ul><li>Coagulopathy </li></ul>
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